WOUND ASSESSMENT USING TIME 2013

Jeannie Randles RNGrad cert wound care

PG Cert &PG Dip Primary Health

Assess whole patient not hole in the patient

outline

documentation Wound healing process Chronic wounds Wound assessment using TIME

Documentation !!!

Assess wound assessment

forms and notes Re assess Read previous

documentation Care plan (up to date

and clear) Outcomes (up to date

and appropriate) If its not written it

didn’t happen!!!!

Wound healing process

cascade of events Haemostasis Inflammation Proliferation Remodelling

Not always in order

haemostasis

Arrest bleeding Vasoconstriction Compression of

injured vessels Platelet activation Fibrin production Clot formation

Inflammation

Vasodilation Leukocyte supplant

platelets White cells

predominant for 1st three days

Monocytes become macrophages and debride the wound

proliferation

Fibroblasts migrate from wound margins Generate cytokines, growth factors,

collagen Capillary loops form(angiogenesis) Inflammation reduces

Types of wound healing

Primary intention – surgical closure, minimises connective tissue deposition, resulting in rapid healing

Secondary intention – wounds that are left open and heal by deposition of connective tissue resulting in increased scar formation

Tertiary (delayed primary) – delayed closure of wounds complicated by infection.

Chronic wounds

• “Chronic wounds are wounds that fail to progress through an orderly and timely sequence of repair”

• Often stay in inflammatory stage or move between stages

http://www.worldwidewounds.com/2004/october/Enoch-Part2/Alternative-Enpoints-To-Healing.html Last Modified: Thursday, 21-Oct-2004 15:19:52 BST

Assess wounds using TIME

TIME

T is for tissue Slough Granulation, healthy or dull/friable Epithelial islands Necrotic tissue Tendon or bone exposed Describe tissue seen in detail and in %’s

slough

granulation

Epithelial islands

Necrotic tissue

Tendon exposed

Inflammation/infection

I is for inflammation or infection

↑ erythema ↑ exudates ↑ pain ↑ wound size ↑ malodour Delay in healing

Tissue becomes friable

↑slough Undermining Bridging pocketing

Infected

Moisture balance

Ideal wound healing environment is moist, not wet and not dry (some exceptions apply)

Describe exudates i.e. amount, colour, odour

Describe effect of exudates i.e. maceration, desiccation

Frequency of dressing changes and condition of dressings at changes i.e. saturated or dry

Macerated

Desiccated

Edges/epethelialisation

E is for edges/epethelialisation Rolled Epethelialising Punched out Sloped Undermining

Rolled wound margin

Rolled margins could suggest a degree of senescence

Healing stopped

Epethelialising

Punched out

Irregular shaped wound margins

Conclusion

Wounds are dynamic and need constant re assessment

Excellent wound care follows excellent wound assessment

Clear documentation is a crucial component of wound assessment

Excellent wound assessment involves the whole of the patient and not just the hole in the patient